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Taking it outside

It’s a scene that for most parents is frustratingly familiar: Outside blooms a perfect summer day, while inside kids drape themselves on furniture, calling out occasionally for snacks or to announce, “I’m bored!” The languor is broken only by trips to the cupboard or refrigerator. And then there is the bewitching power of “screen time,” a force few kids can resist. “TV, texting, Internet chatting, video gaming,” says physician Alexandra Adams, a professor of family medicine with the UW-Madison School of Medicine and Public Health (SMPH). “You name it, they’re doing it.”

As a childhood obesity expert, Adams knows another fact about today’s kids of summer: Many of them are at serious risk of packing on pounds. The children she treats at her practice in the UW Pediatric Fitness Clinic already struggle with weight gain and low fitness levels, and now 90 percent of them are coming back 5 to 10 pounds heavier after the three-month summer break, she says, without an associated increase in height. For young kids and teens, it’s a devastating amount to gain, especially since statistics say those excess pounds may never come off again. And her patients are hardly alone. According to the American Heart Association, one in three American children are now overweight or obese, putting them squarely on the path to adult obesity and at risk for adult diseases, including diabetes, heart disease, arthritis and kidney stones.

“We have kids in our clinic who are type 2 diabetics and hypertensive and on cholesterol medication in their early teens. They look like mini-adults,” Adams says. “They’re physiologically much older in their bodies than they should be. And that’s tragic.”

These troubling trends have led doctors, nutritionists and health advocates to introduce a multitude of anti-obesity programs, including the national “Let’s Move!” campaign started by First Lady Michelle Obama last year. Educational initiatives, healthier school lunch programs, and kid-tailored fitness regimens are all being tried. But amid these carefully orchestrated interventions, a team of CALS and SMPH researchers is now wondering if we’ve missed an obvious part of the prescription, especially for children in summer.

With kids staying indoors in record numbers, what if we just got them to go outside?

This doesn’t mean shuttling them to weekly soccer games or other activities by car; kids today get plenty of that, says Sam Dennis, a CALS landscape architect who specializes in children’s environments and collaborates frequently with Adams. What Dennis has in mind are the outdoor experiences children used to have in the past—the type that 50- and 60-something adults describe when asked to explain how they played as children.

“They’ll say, ‘We didn’t have any equipment and we didn’t have organized teams. We would just go out into the woods and build forts or make mud pies,’” says Dennis, who collects these accounts to inform his design of children’s play spaces. “And they get very caught up and animated in telling stories of how they played in nature as kids.”

These children of 40 and 50 years ago not only played outside more; they were also only one-third as likely to be overweight as their counterparts today. Being outside obviously removes kids from the indoor temptations of snacking and screen time. Plus, research shows that kids who spend more time outdoors are also more likely to be physically active, Dennis says.

Yet like many seemingly simple solutions, this one, too, has a catch. Earlier generations of kids played outdoors and were slimmer for it not because they were somehow healthier or more capable of making good choices than children are today—even though some grownups like to think so.

“It’s not that we were so much smarter,” says SMPH physician and pediatrics professor Aaron Carrel, with a smile. Kids have always been kids. The difference was the environment.

“Obesogenic” is what the Centers for Disease Control and Prevention calls the American landscape today, meaning it promotes unhealthy eating, a sedentary lifestyle, too many calories—and extra pounds. The more fattening aspects of our surroundings are easy to spot: a fast food hamburger and super-sized fries, for example. But what makes obesity so hard to prevent nowadays is that many things that foster weight gain have become part of our everyday lives, says Carrel. We take elevators instead of stairs, we drive instead of walk, we lift our garage doors with the press of a button. As a result, we probably expend 100 to 300 fewer calories each day than people did 30 years ago, while also taking in 100 to 300 more. And those added calories … well, they add up.

“No one gets obese in a day,” says Carrel. “It’s really this few hundred calories every day that makes a difference over a week, a month, a year, and [causes] the systemic accumulation of weight and obesity.”

The same math applies to kids, of course, which is why Carrel co-founded the UW Pediatric Fitness Clinic a decade ago to help overweight children be more active in their daily lives. Through its own interventions and in collaboration with area schools, the clinic has produced dramatic results: Kids routinely trim body fat, improve their fitness and lower their risk for diabetes.

Until summer, that is. Carrel noticed the same alarming trend as Adams. When children came in for check-ups in September, their fitness levels had plunged and they were padded once more with fat. “All the gains they made during the school year were lost,” he says. It told him and Adams that “things really have changed. The summer environment doesn’t always encourage physical activity.”

Dennis agrees, noting that what’s really vanishing is the free, outdoor play of the past, when the only rule was to be home by suppertime and kids would spend hours exploring tangles of woods, splashing through creeks, hunting for snakes under rocks—and, beneficially, exerting themselves, producing vitamin D and connecting with nature. But that kind of play is rare today. “There is no more ‘free range’ childhood,” Dennis says.

In his 2005 book, Last Child in the Woods, journalist Richard Louv discusses the loss of nature play at length, citing the rise of organized activities and video games as top reasons for its demise. But he and Dennis also point to parents. Fearing children will get abducted, injured or even just dirty, parents today keep a close eye on kids and restrict where they go. Even Dennis finds himself doing it. “My mom never knew where I was,” he says. “But I know where my kids are. I’m guilty of it, too.”

Sending children back out to wander the neighborhood obviously isn’t an answer to the childhood obesity crisis—most parents wouldn’t allow it. “So what I’m trying to do,” Dennis says, “is design settings that are like nature, but in very controlled situations like day care settings, or schools, or afterschool programs.” The idea, in other words, is to create environments that will keep kids engaged and active outdoors, even as they’re being supervised.

Working with Adams and tribal members, for example, Dennis designed a playground on the Bad River Indian Reservation in northern Wisconsin that replaced “bright, plastic play equipment” with such natural elements as collections of boulders and culturally relevant features like a willow lodge and ricing canoe. He helped restore an overgrown and underused children’s park on Madison’s west side so that today it beckons kids with grassy paths and piles of dead branches for building forts, along with a previously designed council ring.

But when Adams resolved a few years ago to change the summer environment specifically for overweight kids, it was Dennis’ work with the Madison nonprofit, Community GroundWorks, that caught her eye. For years, Dennis and Community GroundWorks education director, Nathan Larson, had been using another natural setting—the garden—to lure kids outdoors, engage them in meaningful physical fitness and teach them about healthy foods. After a series of meetings, Adams, Dennis, Larson and CALS nutritional sciences professor Dale Schoeller devised an intervention based on the Community GroundWorks model. Led by Schoeller’s graduate student Sarah Jacquart, the GardenFit program would test whether gardening could help kids at risk for obesity stave off those critical summertime pounds.

There are many reasons to think that gardening might work. For one, although gardening is “not basic training, by any means,” says Schoeller, “it’s very easy to work moderate exercise and play into a gardening project.” Moreover, many studies indicate that kids who grow fruits and vegetables themselves are more likely to try them and eat them. Not that veggies somehow magically prevent obesity, Schoeller says. But when people eat larger portions of bulky, low-calorie foods, they tend to consume fewer high-calorie items such as snack foods. “It’s harder to eat excess calories with fruits and vegetables,” he says. “You fill up, plain and simple.”

But these immediate benefits aren’t the only ones. Getting kids outside gives them the opportunity to connect and identify with the outdoors, say Larson and Dennis. And if they develop that affinity, chances are they will carry it into adulthood, where it translates into higher levels of physical activity and “a lot of positive, enduring health outcomes,” Dennis says. “So, there are profound consequences for quality of life, I think.”

This is why the Community GroundWorks programs never focus solely on producing food or putting kids to work, Larson explains. Instead, children are free to roam within the gardens, giving them a sense of what past generations experienced “being out in the wilds of the neighborhood.” He recalls, for example, watching two girls lost in a tangle of raspberry canes on the property, completely engrossed in the pleasure of eating berries even though cars drove by on a road not 10 feet away.

“I think it’s important to realize that a lot of it is the experience,” Larson says. “The garden is a place where children develop a different relationship to food and a different relationship to spending time outside—a higher level of comfort and enjoyment.“

All the lofty goals in the world mean nothing, however, if kids won’t cooperate, as the team soon learned when GardenFit launched two summers ago at Troy Gardens (which are run by Community GroundWorks) on Madison’s north side. Starting a new research project is always complicated, Adams relates, especially when children are involved. “But I think you never have a real sense until you get kids with their hands in the dirt, saying ‘This is boring,’” she says with a laugh.

Jacquart had her hands full, in other words, as she faced a small group of 11- to 13-year-olds who were selected for GardenFit because they were on the cusp of becoming overweight. “Day to day, there was a lot of complaining,” she says. “‘It’s too hot, it’s too hard, I want to sit down.’” Forget gardening, in fact—just being outside for three hours a day was an adjustment, she says. The kids would forget to put on bug spray or sunscreen. Or they would wear white shoes and then grumble when they got soiled.

But Jacquart quickly acquired a new talent—unexpected for a science graduate student—for motivating middle schoolers. Aided by the Community GroundWorks staff, she interspersed water fights and other play amid strenuous tasks like weeding and spreading wood chips. She frequently reminded the young gardeners about the produce they were growing for local food pantries and the skills they were developing. And two days a week, she and the kids fixed healthy lunches of veggie burritos, whole wheat pasta with pesto, pita pocket sandwiches and spring rolls—all bursting with vegetables they had grown themselves. The meals quickly became everyone’s favorite activity by far.

“It was really good. I loved the days we ate out there,” says Jacquart. “You know, fresh from the garden. We’d pick the vegetables right before we were going to prepare them, so that was very cool, I think.”

The grousing continued, but by the end of GardenFit last summer, the kids seemed to agree it had all been very cool. “The feedback we got from them is that they really liked participating, they enjoyed trying new foods and growing them, they got a real sense of accomplishment from working in the garden,” Jacquart says. “They would do it again.”

There was just one thing: The program, on average, failed to prevent weight gain. Some of last year’s GardenFit kids lost weight, she says. But others gained 7 to 10 pounds.

Having spent every day with them for eight weeks, Jacquart heard plenty about the fattening food they were eating on their own time: tacos at the mall, chips at home, bagels and cream cheese at the community center where they spent their early mornings. In the end, she suspects this intake of extra calories swamped out the program’s effects. Even then, the results surprised her. “I mean, we did hard work out there. I came home every day sweaty and covered in dirt and I lost weight over the summer,” she says. “But I also didn’t eat those foods. I ate my normal diet.”

Adams and Schoeller are less surprised; what the findings tell them is that many more children need to be enrolled beyond the six who participated the first summer and the 10 who gardened the second. Collecting data from more kids will make it statistically easier to detect the program’s effects, Schoeller says. It will also help the researchers determine the “dose” of gardening that’s needed to counteract any factors that predispose the kids to weight gain, such as their genetics, as well as their lives at home, adds Adams.

“If they garden for three hours a day and then go home and eat junk food,” she says, ”then clearly three hours isn’t a big enough dose.” The team will run a third season of GardenFit this summer and is hoping eventually to conduct a much bigger trial.

But the GardenFit results convey a larger message about the complexities of battling a health condition that has also become an environmental problem. When obesity stems not just from the summertime play environment, but also from the food environment, the school environment, and the built environment of streets and cities, just how do you fight it?

“On all fronts” seems to be the answer, which is why a group of CALS and SMPH researchers has embarked on a much larger effort. Working with the Bruce-Guadalupe Community School, a Latino charter school affiliated with the United Community Center in Milwaukee, a team that includes Carrel, Dennis and Schoeller will examine the lives and surroundings of 350 students in painstaking detail: what they eat, where they play and how they get to school, as well as their levels of body fat, muscular strength and endurance, and the amount of energy they expend.

Based on what it learns, the team then hopes to offer the community ideas for reshaping school and neighborhood settings so that they naturally encourage behaviors like walking, playing outside and eating nutritious food, says Carrel—rather than constantly asking kids to choose these healthy options over less healthy but more enticing ones. Not that parents and doctors should stop teaching children to make wise choices, he adds. “But I think we need to change the environment a little bit to allow healthy options to be our default.”

As he contemplates the potential of this approach, Dennis recalls the sabbatical break he spent in Costa Rica with his wife and three kids last fall. In the rural town where the family stayed, the electricity went out with nearly every rainstorm (not to mention one hurricane). Not that this really mattered. The house had no television and Dennis’ kids had left their video games in Madison. The only screen time they got was a periodic e-mail exchange with friends back home and an occasional movie rental over the computer.

So, naturally, Dennis’ kids got bored. And then, in what might seem like a minor miracle to some parents, they went outside to play—climbing trees, running around and making their own fun, just like all the other kids in the neighborhood.